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Saturday, May 2, 2015

The Nursing Student's Guide to Tube Feedings

The Nursing Student's Guide to Tube Feedings

I feel like this is a topic that isn't discussed very much in nursing school. Sure that first semester you learn how to drop a NG tube, but when do we decide to give a patient nutrition through a tube? What do I need to look at as a nurse to evaluate that the patient isn't experiencing a complication? What's the difference between enteral and parenteral nutrition? How do we choose which one to give? What's refeeding syndrome?

These were all thoughts that have at some point raced through my mind. I didn't have much experience with feeding tubes prior to six months ago. Now I feel much more better about them. I'd say I feel like a whiz, but well, I know that I still have a lot to learn. Isn't that the beauty of nursing? There's always something more to learn. No matter how confident you feel, you only know the tip of the iceberg. Medicine is a sea of knowledge.

Millions of patients have tube feedings so I'll do my best to give you the quick down and dirty facts on tube feedings.

How do we receive our nutrition?

I receive my nutrition from copious amounts of Reese's Easter Eggs....... and maybe a salad?

We receive nutrients:

Orally through our everyday diets

Oral supplements

Enteral tube feedings- in your gut

Parenteral tube feedings- through your vein

How can I increase the amount of food my patient eats?

There can be many reasons your patient isn't eating. They're sick. They feel like crap. These are some easy tips that I think every nurse should be doing for every single patient.

Assess for pain or nausea and treat it with ordered medications. Or call the doc and request that your patient have a medication for their pain or nausea. You patient may need an appetite stimulant. If your patient is older or receiving chemo they may not have any appetite so that's when you'd want to medicate with a stimulant.

You can easily (ish) make the surroundings more pleasant for the patient. Does the room/unit smell? Can you get rid of that smell? Sometimes you can. Sometimes you cannot. We eat first with our eyes and probably second with our nose. Of course we actually eat with our mouth. The patient might need some special utensils. You might need to assist the patient with eating.

Assisting a patient to eat is probably my most favorite thing in all of nursing to do. (Besides starting an IV.) I LOVE to feed patients. Maybe because I was a caregiver to my grandma and had to help her eat. I'm not sure. I just love giving back to another human being. Another soul. That person is 100% vulnerable and weak and I'm giving them the strength that I have today to help them nourish their bodies. As nurses we all know that some day we will lie in that bed and require the care of other nurses from a generation that's young and full of life. I want to treat others how I'd like to be treated. I love feeding my patients.

Ok. You can also increase how much your patient eats by giving them what they like to eat. I know. It's not a genius idea. I can certainly understand why we need to put patients on cardiac and kidney diets, but at the end of the day if they're not eating those foods it's better to get them something they like verses them starving. Plus we now live in a day and age with many different cultures mixing. Americans eat a ton of carbs. Hey I love bread. I'm not knocking it. But other cultures may eat more fresh fruit or veggies vs our couch potato diets in America. They may not eat pork. Or beef. So we need to be aware of this and make selections that are better suited for them.

Which is better: Enteral or Parenteral?

Enteral nutrition is more common because it has shown to have better outcomes. It also has less severe complications.

Parenteral feedings will require you to give the patient a large amount of fluid because the nutrients need to be diluted other wise they are too harsh on the patient's vein. If you patient has kidney issues, liver issues, congestive heart failure, etc... you don't want to be giving them excess fluids.

If you are giving TPN to a patient and concerned about their fluid volume, give a solution high in fat and low in carbs. Carbs require water to break down.... remember all that kreb cycle, ATP, electron transport chain crap... yep... you needed water and glucose. So that's how you get around that.

What are the complications of tube feedings?

Tube feedings require the healthcare team to constantly look at the blood levels of electrolytes and albumin and transferin if we can get it. If the sodium is high, maybe we switch to a different formula with lower amounts of sodium. We can be giving solutions that are too high or too low in electrolytes and need to make constant adjustments.

Anyways-- like most things in healthcare you have probably realized, our direction of care is determined by the response of the patient. We know their body's response because we look at their lab values. Sure we look at other things, but blood doesn't lie. Usually...

Refeeding Syndrome

This is what I go through every night as I walk back into the kitchen and get a second helping of food.....

Ok. It's not. I'm just a fatty.

Refeeding syndrome happens when you start to introduce food back to a patient. The starving patient's body has become catabolic. When you introduce these nutrients/calories their body goes into anabolism.

Insulin levels increase with the reintroduction of food. Potassium, Magnesium, and Phosphorus get pulled from the blood to the cell and you end up with dangerously low serum levels of them.

This can kill the patient. Karen Carpenter is an example of someone dying from refeeding syndrome.

The body needs more phosphorus so that it can make more ATP and have energy to form intracellular bonds. You really want to watch your patient's phosphorus labs when you're in the beginning phases of introducing tube feeds to the patient.

Patients at risk for refeeding syndrome are:

Anorexics

Alcoholics

Malignacies

Intestinal Malabsorption

Recent surgery on the GI tract

What can I do as the nurse to prevent Refeeding Syndrome?

Recognize who is at risk

Get plasma electrolytes prior to starting the feedings... just like how we like to look at WBC counts and cultures before starting antibiotics

Introduce feedings slowly- because there is that electrolyte shift that will happen when the patient's body goes from catabolism to anabolism.

Get daily labs on phosphorus, sodium, potassium, magnesium, and albumin

******

Basically, with tube feedings we want to make sure that our patient actually needs them. Could we just try to get them to increase their oral intake? Maybe we can. And certainly sometimes we cannot. We want to watch out for fluid volume overload, so we'll probably try to start out with enteral feedings. We want to watch out for our patient's fluid status, electrolyte imbalances, body weight, edema, intake and output. We also want to be aware of the development of Refeeding Syndrome.

This was just a quick guide. My goodness. This is a very lengthy topic. I didn't even address all the different placements of enteral feedings, OG, NG, GJ, NJ..... yada yada..... nor did I talk about pressure ulcers.... or the osmolality and caloric density of the formulas. This is a BIG topic.

Is there something I left out that you think I should've included? What are the things that you assess in your patients receiving tube feedings? Leave us a comment below!

3 comments:

As a registered dietitian, I enjoy reading your posts to become more familiar about nursing practices that I did not learn about during my schooling. Keep writing! The section regarding ways to increase meal intake is wonderful and mentions things to remember about our patients.

However, I do believe there are some aspects of this post that need revising. First, enteral nutrition (tube feeds) should be used if the GI tract is not compromised (extreme vomiting, diarrhea, mucositis, etc) because TPN is not a long-term solution and can increase the risk of developing bloodline infections, electrolyte abnormalities, and fluid overload. Second, the complications with tube feeding are more associated with TPN. Remember, TPN is administered directly into the bloodstream therefore blood levels are affected more quickly compared to tube feeds (monitor potassium magnesium, phosphorus, and blood glucose levels in addition to signs of volume overload). With tube feeds, GI complications should be monitored (gastric residuals, abdominal distention, diarrhea/constipation, nausea/vomiting, etc) in addition to blood glucose levels if diabetes is present. Additionally, remember tube feeds alone do not cause diarrhea, look into medications, disease states, and amount of tube feed flushes. A tube feed formula shouldn't be changed if it can be helped because medications and adjustments in flushes can promote tolerance. Finally, albumin is not a nutritional indicator for malnutrition (I know this was not said) as levels are influenced by multiple factors including presence of inflammation and fluid balance.

These are all WONDERFUL things to keep into consideration when caring for our patients receiving TPN. Thank you so much for sharing your wealth of knowledge.

Sorry, I guess I eluded that TPN is associated with a higher risk for complications, but I didn't directly state that. I agree with everything you said. Always check residuals before giving meds, free water flushes, or restarting feeding. In the adult patient I hold off and contact the doctor if I have over 200 mL residual. Always assess abdominal distention. I didn't mention but when assessing the abdomen for bowel sounds, the patient can be receiving tube feeds (ie via a dobhoff placed in the duodenum) and also have a NG providing suctioning in the stomach to prevent aspiration-- Clamp off the suctioning for a quick moment while you take a listen. I agree that albumin is not a nutritional indicator for malnutrition. Serum transferrin would be better but albumin is all that we get on a metabolic panel. The best thing I've read in regards to albumin is that it is a good predictor at survival from starvation but that transferrin is a better predictor of overall nutrition.

This really is a broad topic and I skipped a lot. I want to make a more detailed post on refeeding syndrome. I want to make one on tube placements. Even how to operate a stopcock. My school didn't teach that.

I appreciate your comment so much. I wished that each profession learned more about each other during school.Thankfully, I have several good friends that are dietitians and they graciously let me pick their brains. I really wished we used the expertise of an RD more in healthcare. There is a huge nutritional knowledge deficit.